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Finding the right balance: prevention and treatment

Dr Lisa Umphrey is a Paediatric medical advisor for Médecins Sans Frontières and discusses her future work in Koutiala, Mali

Seventeen-month-old Aramatou is suffering from oedema and malaria, and this is the third time that she will be referred to from the community health centre to MSF Koutiala Hospital. Once recovered, she will be discharged from the hospital's intensive nutrition unit (URENI), back to the ambulatory feeding program (URENAS)

"The beginning of the year typically involves reflection and looking ahead, and I’m doing my share as I start my first full year as a paediatric advisor for Médecins Sans Frontières’ Medical Unit in Sydney. In my new role I’ll be returning to Koutiala in southern Mali, having first worked in the hospital as a paediatrician in 2014. Koutiala represents our biggest paediatrics project. It begun six years ago in collaboration with the Malian Ministry of Health and is dedicated to tackling endemic malnutrition, malaria, respiratory infections and other common causes of under-five deaths worldwide.

The project stands out within Médecins Sans Frontières. Where others may address either hospital care or community-level care, in Koutiala we’re joining up preventive and curative activities. Médecins Sans Frontières has established expertise in each, ensuring prevention and treatment are complimentary. Our ongoing challenge is how to get the balance right. Many diseases are preventable, but there will always be children whose lives need to be saved with urgent and specialised care. The continuum of care spans from the village, via village health workers and malaria outreach ‘agents’, to the 210-bed paediatric department of Koutiala Reference Hospital. If we miss a child at one point, we’re ensuring we have the opportunity to care for them at another. And if they do need hospitalisation, on discharge many loop back to the community health centre, to complete their nutritional treatment and be enrolled in the preventive program to avoid sickness again.

Youssouf was referred to Koutiala Hospital from Molobala CSCOM for severe pneumonia, and malnutrition.

One-year-old Youssouf did exactly that. His mother brought him to Molobala health centre acutely malnourished, coughing and with very laboured breathing. Acute malnutrition can be treated outside the hospital if it’s not severe, and in Youssouf’s case he was moderate, but his respiratory distress complicated things. His health booklet showed he’d had some vaccinations, but not the full suite. This made him all the more at risk of the severe, indeed life-threatening, pneumonia he was suspected to have. Transferred to hospital he was admitted for medical treatment and nutritional therapy, once his pneumonia resolved he was healthy enough to go home - becoming a nutrition outpatient in Molobala, with weekly check-ups until his acute malnutrition was overcome.

Working with the Ministry, we want to reduce mortality and illness among all 165,000 children aged under-five across the district. This is only possible if we improve the quality of health care in all 42 health zones that belong to Koutiala. The foundation of this is a feasible paediatric package, combining prevention and treatment that is simple and cheap to deliver. The free package of care includes prevention and treatment of malnutrition, immunisation, general medical consultations, provision of insecticidal mosquito nets, and preventive malaria treatment during the malaria season. Every child that can avoid severe sickness and maintain good nutrition is a child more likely to become a healthy adult.

Activities at Molobala CSCOM include vaccination, regular screening, malaria testing and treatment, as well as nutritional support.

Five health centres are now linked with our hospital and the reach is already substantial but it is a number that we’re planning to expand. In 2014, over 10,000 consultations were conducted for monitoring development in healthy children. Another 3,000 malnourished children received ambulatory care. Everyone benefits with ambulatory care. Managed via the health centre, the child avoids becoming sicker, the family avoids the worry and logistical difficulties of a very sick child and the health system can support the child at a lower level, which reduces costs. So far, we have been able to increase vaccination coverage; reduce growth delays for children under two; reduce the numbers of children with severe acute malnutrition; and reduce hospital admissions. These results have given us the confidence—and evidence—to push for roll out across the district.

In 2014, we also saw 4,500 malnourished children hospitalised. Because malnutrition and infection interact, it is easy for children to suffer multiple health issues, making diagnosis and treatment all the more complex. As with Youssouf, and children much sicker than him, we are well equipped to give them the care they need. But my colleagues and I would be so much happier – and the child’s prognosis would be so much better – if they were detected, diagnosed and treated earlier.

"The project has focused on improving systems at all levels of care, and training local community and hospital health workers as well as paramedical trainees and medical students"

The situation with malaria is similar. In 2014 our teams reached over 180,000 children pre-emptively with anti-malarials during the malaria peak. The program, Seasonal Malaria Chemoprevention (SMC), was a huge undertaking. While close to 5,000 patients were still hospitalised for severe and/or complicated malaria, this is significantly down from 8,860 in 2011 before we implemented SMC. Yet we know that we haven’t got the better of malaria yet. We are on our way though, to getting the better of the variety of bacterial diseases that threaten our small patients. As I left Koutiala in May 2014 we finished construction of a renovated blood bank—the source of transfusions for many malaria patients—and laboratory, incorporating a new bacteriology department. This is a luxury compared to the typical Médecins Sans Frontières project, and can really help individualised care.

The project has focused on improving systems at all levels of care, and training local community and hospital health workers as well as paramedical trainees and medical students. In Mali, despite marked poverty, the project has been able to grow via the joint investments in infrastructure, training, and research. We continue to monitor our results, and discussions are ongoing with other aid actors about the specialised roles they can play. Overall, we keep striving to get the balance of investment right, strengthening prevention and treatment for a continuum of care that saves lives like Youssouf’s now, and others well into the future."